The Dangers of Generalizing – Overlooking the Particulars of the Caribbean HIV/AIDS Epidemic John Waters M.D., M.Sc., D.Sc., M.A. (Oxon) COIN CVCC

Overall in the Caribbean the epidemic has been characterized as generalized with concentrated pockets.

Concentrated Epidemic Still opportunity to spare the general public by targeting high risk groups. Generalized Epidemic Focus of the response must shift towards the population at large

Resource limited setting of Caribbean focus on generalized epidemic and resultant prevention targeting the population at large, has occurred at the expense of certain high risk groups who are the central focus in a concentrated epidemic.

3 phenomena have contributed to this classification: 1. A definition of a “generalized epidemic” that is not transmission based. 2. An apparent feminisation of the epidemic in the Caribbean. 3. An emphasis on heterosexual sex as the major transmission mechanism in the region.

1. Generalized/Concentrated epidemic definitions based on prevalence data

-Practical given prevalence data is much more readily available. -Charting progression from a concentrated to generalized epidemic is a dynamic process that prevalence data does not capture well -Incidence data represent a more dynamic indicator as incidence measures the number of new infections

2. Feminization of the epidemic in the Caribbean

Women as percent of Adults (15+) Living with HIV/AIDS by Region, 2007 (Source UNAIDS)

Evolution of Male-to-Female ratio over time. (Source UNAIDS)

Women placed at risk of HIV through sex & gender: 1. Biological vulnerability (2-4 X) 2. Socio/economic vunerablity (Restricted ability to protect themselves in sexual relationships). Involves many different issues including: -Consensual sex in contexts of gender-based violence -Ability for condom negotiation and/or availability of female-controlled prevention measures (e.g. female condom) -Lack of access to education and employment opportunities. (creates economic and social dependence on men making it more likely that women have to exchange sex for money, status, goods or services).

Feminization of epidemic is dependent male sexual behaviour. Caribbean HIV transmission through blood transfusion or needle sharing is not common => Female can only become infected through unprotected sex with an infected male. Two such links have been particularly important in contributing to women becoming infected in the Caribbean 1. The double life of many MSM Trinidad and Tobago study found HIV prevalence in MSM of 20%. It also found that 25% of MSM reported regularly having sex with women. 2. The widespread practice of multiple concurrent sexual partnerships adopted by many men in the Caribbean St. Kitts and Nevis study 18% of adult men reported having bought sex.

Male/Female Ratios Caribbean as a whole

Male/Female Ratios Discarding Hispaniola

3. An emphasis on heterosexual sex as the major transmission mechanism in the region

Self reported sexual identity in CMCs

-1 st medical term coined to describe the condition later linked with HIV, was Gay-Related Immune Deficiency (GRID) -Discovery of other transmission mechanisms (transfusion, IV) First HIV test becomes available (ability to diagnose prior to dev. of full blown AIDS) - Homophobia was building up as it became increasing apparent that the disease was affecting the wider population, and homosexuals were blamed for bringing the disease -Illegal context and religious condemnation of MSM activity

Male Risk Category by Year in Trinidad & Tobago

The Concentrated Epidemic

Prevalence of HIV in Transgender persons versus Homosexual and Bisexual males

-Although in a generalized epidemic HIV can become entrenched in the general population, it is unlikely that sexual networking in the general population is sufficient to sustain an epidemic without the “cross pollination” of high risk groups. -PANCAP in its round 10 Global Fund proposal has taken a bold step to redress the situation by making MARPs central to the response.

The Dangers of Generalizing – Overlooking the Particulars of the Caribbean HIV/AIDS Epidemic A cautionary note that plays on the word “generalized” -We need to be careful not to overlook MARPs in stressing a “generalized epidemic” -We need to be cautious not to “generalize” about the epidemic in the region because we have different types of epidemics ranging from purely concentrated to mixed epidemics.